School Nutrition Environment and Services: Policies and Practices That Promote Healthy Eating Among K-12 Students.

BACKGROUND: Changes to policies at the federal, state, and local levels over the last decade have influenced the school nutrition environment and services. METHODS: This systematic review includes an analysis of individual research articles and government reports published from 2010 to 2021 that examine interventions to improve the school nutrition environment and services and increase the availability, selection, and consumption of healthier foods and beverages in K-12 schools in the United States. RESULTS: Nutrition standards for school meals and food outside of meals improved access to healthier options in school. Providing school nutrition professionals with professional development, improving the palatability of school meals, offering taste tests, pre-slicing fruit, providing recess before lunch, offering incentives for trying healthier options, and providing access to drinking water resulted in increased selection and consumption of healthier items. There were inconclusive or mixed findings for some intervention strategies including adequate seat time for meals. CONCLUSIONS: Despite demonstrated improvements to school meal programs and competitive foods, more work is needed to change the selection and consumption of healthier options among K-12 students. Schools can use multiple interventions to improve the school nutrition environment and services and help students adopt food and beverage choices that support health.

Coordinated Approach: Comprehensive Policy and Action Planning.

BACKGROUND: Schools play a vital role in student health, and a collaborative approach may affect health factors such as physical activity (PA) and nutrition. There is a lack of recent literature synthesizing collaborative approaches in K-12 settings. We present updated evidence about interventions that used a coordinated school health approach to support K-12 student PA and nutrition in the United States. METHODS: A 2-phase literature review search included a search of systematic reviews for individual qualifying studies (2010-2018), followed by a search for individual articles (2010-2020) that evaluated a coordinated approach or use of school wellness councils, committees, or teams to address PA and/or nutrition. RESULTS: We identified 35 articles describing 30 studies and grouped them by intervention type. Interventions demonstrated promising findings for environmental changes and student dietary and PA behaviors. IMPLICATIONS: Coordinated and multicomponent interventions demonstrated significant improvements or null results, indicating that implementation of programs and/or policies to promote healthier eating and PA practices may support and do not appear to hinder environmental or behavioral outcomes. CONCLUSIONS: Schools can use a coordinated approach to implement opportunities for PA and nutrition; this may influence students' PA and dietary behaviors.

Associations between Knowledge of Health Risks and Sugar-Sweetened Beverage Intake among US Adolescents.

BACKGROUND: Sugar-sweetened beverage (SSB) intake is associated with adverse health outcomes. OBJECTIVE: We examined associations between the knowledge of health risks related to SSB and SSB intake among adolescents. DESIGN: A cross-sectional study using 2021 YouthStyles survey data. PARTICIPANTS/SETTINGS: 831 US adolescents (12-17 years old). MAIN OUTCOME MEASURES: The outcome variable was SSB intake (none, 1-6 times/week, and ≥1 time/day). Exposure variables were knowledge of seven SSB-related health risks. STATISTICAL ANALYSES PERFORMED: Seven multinomial regressions were used to estimate adjusted odds ratios (AOR) for drinking SSB, according to knowledge of SSB-related health risks and after controlling for sociodemographics. RESULTS: Overall, 29% of adolescents consumed SSB ≥1 time/day. Although most adolescents identified cavities (75.4%), weight gain (74.6%), and diabetes (69.7%) as being related to drinking SSB, fewer adolescents identified related conditions such as high blood pressure (31.7%), high cholesterol (25.8%), heart disease (24.6%), and some cancers (18.0%). Compared to non-SSB consumers, drinking SSB ≥1 time/day was significantly higher among adolescents who lacked knowledge of associations between SSB intake and weight gain (AOR = 2.0), heart disease (AOR = 1.9), or some cancers (AOR = 2.3) after controlling for covariates. CONCLUSIONS: Among US adolescents, knowledge of SSB-related health risks varied by condition, ranging from 18% (some cancers) to 75% (cavities and weight gain). There were increased odds of drinking SSB among those unaware that weight gain, heart disease, and some cancers are associated with SSB intake. Intervention could evaluate whether increasing certain types of knowledge may influence youth SSB intake.

Dietary and Physical Activity Behaviors in 2021 and Changes from 2019 to 2021 Among High School Students - Youth Risk Behavior Survey, United States, 2021.

The fall of 2021 was the first school semester to begin with widespread in-person learning since the COVID-19 pandemic began. Understanding dietary and physical activity behaviors of adolescents during this time can provide insight into potential health equity gaps and programmatic needs in schools and communities. This report uses data from the 2021 national Youth Risk Behavior Survey conducted among a nationally representative sample of U.S. public and private school students in grades 9-12 to update estimates of dietary and physical activity behaviors among U.S. high school students overall and by sex and race and ethnicity. In addition, 2-year comparisons (2019 versus 2021) of these behaviors were examined. In 2021, daily consumption of fruits, vegetables, and breakfast during the past 7 days remained low and decreased overall with specific disparities by sex and race and ethnicity from 2019 to 2021. The overall prevalence of students attending physical education classes daily, exercising to strengthen muscles on ≥3 days/week (i.e., met the guideline for muscle-strengthening activity), and playing on at least one sports team decreased from 2019 to 2021; whereas being physically active for ≥60 minutes/day on all 7 days (i.e., met the guideline for aerobic activity) and meeting both aerobic and muscle-strengthening guidelines remained low but did not change. These findings underscore the need for strategies to increase healthy dietary and physical activity behaviors both in the recovery phase of COVID-19 and longer term.

Family Economics and Mental Health Among High-School Students During COVID-19.

INTRODUCTION: The COVID-19 pandemic has had unprecedented socioeconomic and health impacts in the U.S. This study examined racial/ethnic and school poverty status differences in the relationship between parent job loss, experiences with hunger, and indicators of mental health problems among public high-school students nationwide during the COVID-19 pandemic. METHODS: The study analyzed data from the Adolescent Behaviors and Experiences Survey, conducted in January-June 2021. The Adolescent Behaviors and Experiences Survey was a 1-time, cross-sectional, online survey that used a stratified, 3-stage cluster sample to obtain a nationally representative sample of high-school students in the U.S. This study was limited to public-school students (n=7,379). RESULTS: Among public high-school students nationwide, 36.9% experienced poor mental health during the pandemic, and during the past year, 43.9% experienced persistent feelings of sadness or hopelessness, 19.8% seriously considered attempting suicide, and 9.1% attempted suicide. Parent job loss and having gone hungry were associated with indicators of mental health problems overall and across racial/ethnic groups and school poverty status levels. CONCLUSIONS: Students who experience parent job loss and hunger are likely to also experience poor mental health and may be at higher risk for suicide.

A Community Guide Systematic Review: School Dietary and Physical Activity Interventions.

CONTEXT: Schools can play an important role in supporting a healthy lifestyle by offering nutritious foods and beverages and providing opportunities for physical activity. A healthy diet and regular physical activity may reduce the risk of obesity. This manuscript reports on a Community Guide systematic review examining the effectiveness of interventions in schools combining school meal or fruit and vegetable snack programs and physical activity. EVIDENCE ACQUISITION: Studies meeting the intervention definition were identified from a literature search (search period: January 1990-November 2019). Community Guide systematic review methods were used to assess effectiveness as measured by dietary behavior, physical activity, and weight changes; analyses were conducted in 2020. EVIDENCE SYNTHESIS: Interventions (n=24 studies) were considered effective for increasing physical activity (median increase=21.8 minutes/day; interquartile interval= -0.8 to 27.4 minutes/day), modestly increasing fruit and vegetable intake (median relative increase=12.1%; interquartile interval= -4.6%, 73.4%), and decreasing the prevalence of overweight and obesity (median decrease=2.5 percentage points; interquartile interval= -8.1, -1.6 percentage points) among elementary school students through sixth grade. There were not enough studies to determine the effectiveness of interventions for middle- and high-school students. CONCLUSIONS: School meal or fruit and vegetable snack interventions combined with physical activity were effective in increasing physical activity, with modest effects for improving fruit and vegetable consumption and reducing the prevalence of overweight and obesity among elementary students. These results may inform researchers and school administrators about healthy eating and physical activity interventions.

Disruptions to School and Home Life Among High School Students During the COVID-19 Pandemic - Adolescent Behaviors and Experiences Survey, United States, January-June 2021.

Youths have experienced disruptions to school and home life since the COVID-19 pandemic began in March 2020. During January-June 2021, CDC conducted the Adolescent Behaviors and Experiences Survey (ABES), an online survey of a probability-based, nationally representative sample of U.S. public- and private-school students in grades 9-12 (N = 7,705). ABES data were used to estimate the prevalence of disruptions and adverse experiences during the pandemic, including parental and personal job loss, homelessness, hunger, emotional or physical abuse by a parent or other adult at home, receipt of telemedicine, and difficulty completing schoolwork. Prevalence estimates are presented for all students and by sex, race and ethnicity, grade, sexual identity, and difficulty completing schoolwork. Since the beginning of the pandemic, more than half of students found it more difficult to complete their schoolwork (66%) and experienced emotional abuse by a parent or other adult in their home (55%). Prevalence of emotional and physical abuse by a parent or other adult in the home was highest among students who identified as gay, lesbian, or bisexual (74% emotional abuse and 20% physical abuse) and those who identified as other or questioning (76% and 13%) compared with students who identified as heterosexual (50% and 10%). Overall, students experienced insecurity via parental job loss (29%), personal job loss (22%), and hunger (24%). Disparities by sex and by race and ethnicity also were noted. Understanding health disparities and student disruptions and adverse experiences as interconnected problems can inform school and community initiatives that promote adolescent health and well-being. With community support to provide coordinated, cross-sector programming, schools can facilitate linkages to services that help students address the adverse experiences that they faced during the ongoing COVID-19 pandemic. Public health and health care professionals, communities, schools, families, and adolescents can use these findings to better understand how students' lives have been affected during the pandemic and what challenges need to be addressed to promote adolescent health and well-being during and after the pandemic.

Individual and Collective Positive Health Behaviors and Academic Achievement Among U.S. High School Students, Youth Risk Behavior Survey 2017.

PURPOSE: We examined associations between academic grades and positive health behaviors, individually and collectively, among U.S. high school students. DESIGN: Cross-sectional study design. SETTING: Data were from the 2017 national Youth Risk Behavior Survey. Response rates were 75% for schools, 81% for students, and 60% overall (n = 14,765 students). SUBJECTS: Youth in grades 9th-12th. MEASURES: We focused on youth behaviors that can prevent or delay the onset of chronic health conditions. Seven dietary, 3 physical activity, 2 sedentary screen time, and 4 tobacco product use behaviors were assessed. Variables were dichotomized (0/1) to indicate that a score was given to the positive health behavior response (e.g.,, did not smoke cigarettes = 1). A composite score was created by summing each positive health behavior response among 16 total health behaviors. ANALYSIS: Multivariable logistic regression analyses for each individual health behavior, and a multivariable negative binomial regression for the composite score, were conducted with self-reported academic grades, controlling for sex, grade in school, race/ethnicity, and body mass index (BMI) categories. RESULTS: Controlling for covariates, students who reported mostly A's had 2.0 (P < .001) more positive health behaviors; students who reported mostly B's had 1.3 (P < .001) more positive health behaviors; and students who reported mostly C's had .78 (P < .001) more positive health behaviors, compared to students who reported mostly D's/F's. CONCLUSIONS: Higher academic grades are associated with more positive individual and cumulative health behaviors among high school students. Understanding these relationships can help inform efforts to create a healthy and supportive school environment and strive for health equity.

Percentage of Adolescents Meeting Federal Fruit and Vegetable Intake Recommendations - Youth Risk Behavior Surveillance System, United States, 2017.

According to the 2020-2025 Dietary Guidelines for Americans, persons should consume fruits and vegetables as part of a healthy eating pattern to reduce their risk for diet-related chronic diseases, such as cardiovascular disease, type 2 diabetes, some cancers, and obesity.* A healthy diet is important for healthy growth in adolescence, especially because adolescent health behaviors might continue into adulthood (1). The U.S. Department of Agriculture (USDA) recommends minimum daily intake of 1.5 cups of fruit and 2.5 cups of vegetables for females aged 14-18 years and 2 cups of fruit and 3 cups of vegetables for males aged 14-18 years.† Despite the benefits of fruit and vegetable consumption, few adolescents consume these recommended amounts (2-4). In 2013, only 8.5% of high school students met the recommendation for fruit consumption, and only 2.1% met the recommendation for vegetable consumption (2). To update the 2013 data, CDC analyzed data from the 2017 national and state Youth Risk Behavior Surveys (YRBSs) to describe the percentage of students who met intake recommendations, overall and by sex, school grade, and race/ethnicity. The median frequencies of fruit and vegetable consumption nationally were 0.9 and 1.1 times per day, respectively. Nationally, 7.1% of students met USDA intake recommendations for fruits (95% confidence interval [CI] = 4.0-10.3) and 2.0% for vegetables (upper 95% confidence limit = 7.9) using previously established scoring algorithms. State-specific estimates of the percentage of students meeting fruit intake recommendations ranged from 4.0% (Connecticut) to 9.3% (Louisiana), and the percentage meeting vegetable intake recommendations ranged from 0.6% (Kansas) to 3.7% (New Mexico). Additional efforts to expand the reach of existing school and community programs or to identify new effective strategies, such as social media approaches, might help address barriers and improve adolescent fruit and vegetable consumption.

Dietary and Physical Activity Behaviors Among High School Students - Youth Risk Behavior Survey, United States, 2019.

Establishing healthy dietary and physical activity patterns among youths is an important public health strategy for improving health and preventing chronic diseases; however, few adolescents meet U.S. government recommendations for dietary or physical activity behaviors, and disparities by sex and race/ethnicity exist. CDC analyzed data from the 2019 Youth Risk Behavior Survey to update estimates of dietary and physical activity behaviors among U.S. high school students overall and by sex and race/ethnicity. In addition, 2-year comparisons (2017 and 2019) and trends in prevalence of these behaviors during 2009-2019 were examined. In 2019, overall, during the 7 days before the survey, 41.8% of students had eaten fruit or drunk 100% fruit juices <1 time/day; 40.7% had eaten vegetables <1 time/day; and 16.7% had not eaten breakfast on all 7 days. Moreover, although 57.4% of students had played on ≥1 sports team during the 12 months before the survey, less than half of students had been physically active for ≥60 minutes/day on all 7 days (23.2%), had exercised to strengthen or tone their muscles on ≥3 days/week (49.5%), had met both aerobic and muscle-strengthening physical activity guidelines (16.5%), or had attended physical education classes on all 5 days in an average school week (25.9%). Trend data indicate limited progress in shifting dietary and physical activity behaviors. That is, with the exception of decreases in the percentage of students who had consumed soda ≥1 time/day (2009: 29.2%; 2019: 15.1%), sports drinks ≥1 time/day (2015: 13.8%; 2019: 10.6%), and <3 glasses/day of plain water (2015: 50.5%; 2019: 44.6%), high school students' dietary and physical activity behaviors have not improved and, in certain cases, have worsened. These findings support the need for multicomponent approaches, including policy and environmental changes, and opportunities for adolescents to learn about and practice making healthy choices.

Physical activity, sedentary, and dietary behaviors associated with indicators of mental health and suicide risk.

We used data from the 2017 national Youth Risk Behavior Survey to examine associations between physical activity, sedentary, and healthy dietary behaviors and indicators of mental health, suicidal thoughts, and suicidal attempts among a representative sample of US high school students. Sex-stratified logistic regression was used to separately model each mental health-related outcome on the health-related behaviors, while controlling for race/ethnicity, grade, and body weight status. Significant associations were found between insufficient physical activity, sedentary, and less healthy dietary behaviors and the mental health-related outcomes. Feeling sad and hopeless was associated with not eating breakfast on all 7 days (past week), drinking soda or pop (female only), not meeting the aerobic physical activity guideline (male only), not playing on at least one sports team, and playing video/computer games or using a computer more than two hours (per day). Suicidal thoughts were associated with not eating breakfast on all 7 days, drinking soda or pop, not meeting the aerobic physical activity guideline, and playing video/computer games or using a computer more than two hours per day. Attempted suicide was associated with not eating breakfast on all 7 days, drinking soda or pop, drinking sports drinks, watching television more than two hours per day, and playing video or computer games or using a computer more than two hours per day (male only). While limiting sedentary behaviors and increasing physical activity and healthy dietary behaviors is not a sole solution for improving mental health among adolescents, it could be another possible strategy used in schools to benefit all students.

Healthier Food and Beverage Interventions in Schools: Four Community Guide Systematic Reviews.

CONTEXT: Healthy eating during childhood is important for optimal growth and helps reduce the risk of obesity, which has potentially serious health consequences. Changing the school food environment may offer one way to improve students' dietary intake. This manuscript reports 4 Community Guide systematic reviews examining the effectiveness of interventions in schools promoting healthy eating and weight. EVIDENCE ACQUISITION: School obesity prevention programs aiming to improve diet were identified from a 2013 Agency for Health Care Research and Quality systematic review and an updated search (August 2012-January 4, 2017). In 2017-2018, Community Guide systematic review methods were used to assess effectiveness as determined by dietary behavior and weight changes. EVIDENCE SYNTHESIS: Interventions improving school meals or offering fruits and vegetables (n=27 studies) are considered effective. Evidence is insufficient to determine the effectiveness of interventions supporting healthier snack foods and beverages outside of school meal programs given inconsistent findings (n=13 studies). Multicomponent interventions to increase availability of healthier foods and beverages are considered effective. These interventions must include 1 component from school meals or fruit and vegetable programs and interventions supporting healthier snack foods and beverages (n=12 studies). There is insufficient evidence to determine the effectiveness of interventions to increase water access because only 2 studies met inclusion criteria. CONCLUSIONS: A total of 2 school-based dietary interventions have favorable effects for improving dietary habits and modest effects for improving or maintaining weight. More evidence is needed regarding interventions with insufficient findings. These reviews may inform researchers and school administrators about healthy eating and obesity prevention interventions.

Hiring Requirements and Qualifications of School Food Authority Directors Changed in Some Districts After Implementation of US Department of Agriculture Professional Standards.

BACKGROUND: In 2015, the US Department of Agriculture set minimum education and training requirements (ie, professional standards) to ensure that school nutrition professionals have the knowledge and experience to operate school meal programs. No study to date has examined whether hiring requirements and qualifications of school food authority (SFA) directors have changed since 2015. OBJECTIVE: To assess changes in hiring requirements and qualifications of SFA directors since the US Department of Agriculture professional standards were established, overall and by district size. DESIGN: Cross-sectional analysis of nationally representative district-level data from the 2012 and 2016 cycles of the School Health Policies and Practices Study. PARTICIPANTS/SETTING: In 2012, 660 sampled districts completed the School Health Policies and Practices Study Nutrition Services questionnaire. In 2016, 599 sampled districts completed the questionnaire. MAIN OUTCOME MEASURES: Hiring requirements for newly hired SFA directors and reported qualifications of SFA directors. STATISTICAL ANALYSES PERFORMED: Differences in prevalence estimates from 2012 to 2016 for all districts and by district size were assessed with χ2 tests. RESULTS: Significant increases were found for 3 hiring requirements: degree in nutrition or related field, registered dietitian credential, and food safety certification. Significant changes in 4 of the 5 reported qualifications were found including an increase in the percentage of district directors with a degree in nutrition or a related field and decreases in the percentage of directors with a School Nutrition Specialist credential from the School Nutrition Association, School Nutrition Association certifications, and certified dietary managers. Changes were found in small and medium districts, but not large districts. CONCLUSIONS: District hiring requirements and SFA director qualifications have changed since the implementation of the US Department of Agriculture professional standards, including some differences by district size. Future research could identify challenges facing districts in hiring directors who have a degree in nutrition or related fields or who have specialized nutrition credentials or certificates (eg, registered dietitians).

Correlates of Infrequent Plain Water Intake Among US High School Students: National Youth Risk Behavior Survey, 2017.

PURPOSE: To examine factors associated with frequency of plain water (ie, tap, bottled, and unflavored sparkling water) intake among US high school students. DESIGN: Quantitative, cross-sectional study. SETTING: The 2017 national Youth Risk Behavior Survey data. SUBJECTS: US high school students with plain water intake data (N = 10 698). MEASURES: The outcome was plain water intake. Exposure variables were demographics, academic grades, and behavioral characteristics. ANALYSIS: We used logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CIs) for factors associated with infrequent plain water intake (<3 vs ≥3 times/day). RESULTS: Overall, 48.7% of high school students reported drinking plain water <3 times/day. Factors associated with infrequent plain water intake were younger age (≤15 years; aOR = 1.20, CI = 1.05-1.37); earning mostly D/F grades (aOR = 1.37, CI = 1.07-1.77); consuming regular soda 1 to 6 times/week (aOR = 1.92, CI = 1.67-2.20) or ≥1 time/day (aOR = 3.23, CI = 2.65-3.94), sports drinks 1 to 6 times/week (aOR = 1.30, CI = 1.14-1.49), milk <2 glasses/day (aOR = 1.51, CI = 1.31-1.73), fruits <2 times/day (aOR = 1.92, CI = 1.66-2.22), and vegetables <3 times/day (aOR = 2.42, CI = 2.04-2.89); and being physically active ≥60 minutes/day on <5 days/week (aOR = 1.83, CI = 1.60-2.08). Students with obesity were less likely to have infrequent water intake (aOR = 0.63, CI = 0.53-0.74). CONCLUSIONS: Infrequent plain water intake was associated with younger age, poor academic grades, poor dietary behaviors, and physical inactivity. These findings can inform intervention efforts to increase water intake to promote healthy lifestyles among adolescents.

Examining differences in the implementation of school water-quality practices and water-access policies by school demographic characteristics.

Ensuring safe, accessible drinking water in schools is a national health priority. The objective of this study was to identify whether there are differences in water quality, availability, and education- related practices in schools by demographic characteristics. In 2017-2018, we analyzed data from the 2014 School Health Policies and Practices Study (SHPPS), a nationally representative, cross-sectional survey of US schools. Analyses examined differences in water-related practices by school characteristics. Response rates for the 3 questionnaires used in this analysis ranged from 69%-94% (Ns ranged from 495 to 577). We found that less than half of schools flush drinking water outlets after periods of non-use (46.4%), conduct periodic inspections that test drinking water outlets for lead (45.8%), and require staff training on drinking water quality (25.6%). Most schools teach the importance of water consumption (81.1%) and offer free drinking water in the cafeteria (88.3%). Some water-related school practices differed by school demographic characteristics though no consistent patterns of associations by school characteristics emerged. In US schools, some water quality-related practices are limited, but water availability and education-related practices are more common. SHPPS data suggest many schools would benefit from support to implement best practices related to school-drinking water.

Practices That Support and Sustain Health in Schools: An Analysis of SHPPS Data.

BACKGROUND: The Whole School, Whole Community, Whole Child (WSCC) model provides an organizing framework for schools to develop and implement school health policies, practices, and programs. The purpose of this study was to examine the presence of practices that support school health for each component of the WSCC model in US schools. METHODS: Data from the School Health Policies and Practices Study 2014 were analyzed to determine the percentage of schools with practices in place that support school health for WSCC components. RESULTS: Less than 27% of schools had a school health council that addressed any specific WSCC component, but more than 50% had a coordinator for all but one component. The use of other practices that support school health varied widely across the WSCC components. For example, more than 80% of schools reported family engagement for health education and nutrition environment and services, but less than 50% reported family engagement for other components. CONCLUSIONS: These results indicate that many US schools are using practices that support school health and align with WSCC components, but improvement is needed. These results also highlight discrepancies in the types of practices being used.

State-Level Guidance and District-Level Policies and Practices for Food Marketing in US School Districts.

State agencies play a critical role in providing school districts with guidance and technical assistance on school nutrition issues, including food and beverage marketing practices. We examined associations between state-level guidance and the policies and practices in school districts regarding food and beverage marketing and promotion. State policy guidance was positively associated with districts prohibiting advertisements for junk food or fast food restaurants on school property. Technical assistance from states was negatively associated with 2 district practices to restrict marketing of unhealthy foods and beverages, but positively associated with 1 practice to promote healthy options. These findings may help inform the guidance that states provide to school districts and help identify which districts may need additional assistance to address marketing and promotion practices.

School health implementation tools: a mixed methods evaluation of factors influencing their use.

BACKGROUND: The U.S. Centers for Disease Control and Prevention (CDC) develops tools to support implementation of evidence-based interventions for school health. To advance understanding of factors influencing the use of these implementation tools, we conducted an evaluation of state, school district, and local school staffs' use of four CDC tools to support implementation of physical activity, nutrition, health education, and parent engagement. Two frameworks guided the evaluation: Interactive Systems Framework (ISF) for Dissemination and Implementation and Consolidated Framework for Implementation Research (CFIR). METHODS: The evaluation applied a mixed methods, cross-sectional design that included online surveys (n = 69 state staff from 43 states), phone interviews (n = 13 state staff from 6 states), and in-person interviews (n = 90 district and school staff from 8 districts in 5 states). Descriptive analyses were applied to surveys and content analysis to interviews. RESULTS: The survey found that the majority of state staff surveyed was aware of three of the CDC tools but most were knowledgeable and confident in their ability to use only two. These same two tools were the ones for which states were most likely to have provided training and technical assistance in the past year. Interviews provided insight into how tools were used and why use varied, with themes organized within the ISF domain "support strategies" (e.g., training, technical assistance) and four CFIR domains: (1) characteristics of tools, (2) inner setting, (3) outer setting, and (4) individuals. Overall, tools were valued for the credibility of their source (CDC) and evidence strength and quality. Respondents reported that tools were too complex for use by school staff. However, if tools were adaptable and compatible with inner and outer setting factors, state and district staff were willing and able to adapt tools for school use. CONCLUSIONS: Implementation tools are essential to supporting broad-scale implementation of evidence-based interventions. This study illustrates how CFIR and ISF might be applied to evaluate factors influencing tools' use and provides recommendations for designing tools to fit within the multi-tiered systems involved in promoting, supporting, and implementing evidence-based interventions in schools. Findings have relevance for the design of implementation tools for use by other multi-tiered systems.